Provider Demographics
NPI:1932299294
Name:BOUDIN, MARY ANNE (PHD)
Entity Type:Individual
Prefix:MS
First Name:MARY ANNE
Middle Name:
Last Name:BOUDIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY ANNE
Other - Middle Name:
Other - Last Name:LLOYD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3900 E VALLEY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4954
Mailing Address - Country:US
Mailing Address - Phone:425-251-0698
Mailing Address - Fax:425-251-8974
Practice Address - Street 1:3900 E VALLEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4954
Practice Address - Country:US
Practice Address - Phone:425-251-0698
Practice Address - Fax:425-251-8974
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1051103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1051OtherLICENSE
WAG8881323OtherMEDICARE PTAN